Should Skull Reconstruction Be Done for Comatose Patients After Severe Head Injury?

Q: Should Skull Reconstruction Be Done for Comatose Patients After Severe Head Injury?

Hello： For general traumatic brain injuries, early assessment and reduction of swelling are important. <br>If possible, skull fractures can be repaired early, which can be beneficial for brain recovery. <br>You may want to consult with a neurosurgeon for evaluation at Changhua Ho

In cases of severe head trauma from a car accident where the patient has been in a coma for several months, is it necessary to first repair the skull?

My mother is in her 50s and was involved in a serious car accident in mid-October, resulting in severe head trauma and coma, along with hydrocephalus.
Initially, due to elevated intracranial pressure and the presence of a hematoma, a portion of her right skull was removed during surgery.
As of mid-January, the doctors diagnosed her with a Glasgow Coma Scale score of E2VTM2.
She remains in a comatose state, but occasionally opens her eyes, frowns, sneezes, and responds to pain, although her eyes appear to lack focus.
She is currently on a ventilator and has a tracheostomy.
It has been about four months since the accident, and she is still in a coma.
The neurosurgeon previously indicated that her brain injury is severe and has affected the areas responsible for consciousness, making it uncertain whether she will regain consciousness (it could take months, years, or even decades).

In this condition, is it appropriate to replace the skull? The neurosurgeon at the initial emergency hospital suggested that replacing the skull could aid in brain recovery.
However, the doctors at the current hospital (respiratory care) advise against replacing the skull at this time and recommend further observation for a few months.
They mentioned that surgery carries risks, and anesthesia might impact the patient's consciousness (a patient who might have awakened could remain in a coma due to the effects of anesthesia).
I am unsure if this is indeed the case.
My family and I have found information suggesting that for conscious patients, prompt skull replacement seems beneficial, but we have not found relevant recommendations for comatose patients.
It seems that both doctors have valid points, and I am uncertain whether we should proceed with skull replacement quickly or wait and observe.

Ms. J, 20~29 year old female. Ask Date: 2023/02/15

Dr. Zhao Shaoqing reply Neurosurgery

Hello: For general traumatic brain injuries, early assessment and reduction of swelling are important.
If possible, skull fractures can be repaired early, which can be beneficial for brain recovery.
You may want to consult with a neurosurgeon for evaluation at Changhua Hospital, under the Ministry of Health and Welfare.
We care about you.

Reply Date: 2023/02/15

More Info

The decision to perform skull reconstruction in comatose patients after severe head injury is complex and requires careful consideration of various factors, including the patient's overall neurological status, the extent of brain injury, and the potential risks and benefits of the procedure.

In your mother's case, she has experienced a severe head injury resulting in a coma, with a Glasgow Coma Scale (GCS) score indicating a significant level of impairment (E2VTM2). The presence of elevated intracranial pressure and the need for decompression surgery (removal of the skull) are common in such cases to prevent further brain damage. The fact that she occasionally opens her eyes and responds to pain is a positive sign, but it does not necessarily indicate a clear path to recovery.

Regarding skull reconstruction, there are several considerations:
1. Timing of Reconstruction: In general, the timing of skull reconstruction can vary. Some studies suggest that early reconstruction may help improve outcomes in patients who are awake and responsive, as it can help restore normal intracranial pressure and protect the brain. However, in patients who are comatose, the benefits are less clear. The risk of anesthesia and surgery in a patient who is not stable can outweigh the potential benefits.

2. Risks of Surgery: As you mentioned, there are inherent risks associated with any surgical procedure, particularly in patients with compromised neurological status. Anesthesia can pose additional risks, especially in patients with severe brain injuries, as it may affect their level of consciousness and complicate recovery.

3. Current Medical Opinions: The differing opinions from the neurosurgeon and the respiratory care team reflect the complexity of your mother's condition. The neurosurgeon may be considering the potential benefits of reconstruction for brain protection and pressure regulation, while the respiratory team may prioritize her current stability and the risks associated with surgery.

4. Monitoring and Observation: Given that your mother has been in a comatose state for four months, it may be prudent to continue monitoring her condition closely. If her neurological status shows signs of improvement, it may become more appropriate to consider reconstruction. Conversely, if her condition remains stable or worsens, delaying the procedure may be advisable.

5. Consultation with Specialists: It is crucial to have ongoing discussions with her medical team, including neurologists and neurosurgeons, to weigh the risks and benefits of surgery. They can provide insights based on her specific medical history and current condition.

In conclusion, the decision to proceed with skull reconstruction in a comatose patient is not straightforward and should be made collaboratively with the medical team, considering the patient's unique circumstances. It may be beneficial to seek a second opinion or further clarification from the neurosurgeon regarding the rationale for reconstruction and the potential impact on your mother's recovery. Ultimately, the goal is to ensure the best possible outcome for her health and well-being.

Similar Q&A

Should My Elderly Father Undergo Skull Reconstruction After Head Injury?

On April 22 at 10:00 AM, my father was involved in a car accident. That afternoon, he experienced intracranial hemorrhage exceeding 30% of blood volume, necessitating an emergency surgery that evening to relieve intracranial pressure. He has now been hospitalized for one month an...

Dr. Zhao Shaoqing reply Neurosurgery
Hello; after a physician assesses that the brain condition is relatively stable, it is generally recommended to reattach and secure the skull defect. Besides improving the aesthetic appearance after cranial reconstruction and protecting the extremely delicate brain tissue, it als...

Understanding Skull Surgery and Recovery After Severe Head Injury

Hello, doctor. My husband fell to the ground at work, landing on his head. At first, he was able to stand up and walk, but within three minutes, he started to have a nosebleed and fainted. He underwent emergency surgery to remove part of his skull on the left side, which was pres...

Dr. Zhang Junwei reply Neurosurgery
Generally speaking, returning the skull to its original position can aid in the recovery of the patient's neurological function. Using the patient's own bone does carry a higher risk of infection, while artificial cranial implants present a lower risk of infection as an...

Understanding Craniotomy: Risks and Recovery After Stroke Surgery

Due to a stroke causing increased intracranial pressure, a craniectomy was performed, which poses a life-threatening risk. After this surgery, is it necessary to reattach the bone? If the bone is not replaced, what other complications might arise?

Dr. Hong Xuyi reply Neurosurgery
Hello, Ms. Mulan. Generally speaking, whether to perform cranioplasty after craniectomy or to reimplant autologous bone grafts from other sites depends on several factors. The primary indication is that the patient is able to mobilize (such as sitting in a wheelchair or undergoin...

Understanding Crushed Skull Fractures and Subdural Hematomas: Risks and Recovery

Hello doctor, my girlfriend was in a car accident and went to the hospital because she was experiencing persistent headaches and nausea. She underwent a CT scan and was initially diagnosed with a concussion. Although she was alert, she experienced sudden dizziness and continued t...

Dr. Zhang Junwei reply Neurosurgery
Without a computed tomography (CT) scan image, I cannot provide you with an accurate answer!